According to Time to Change, over a third of the public think people with a mental health problem are likely to be violent.

Homicide by people who are also patients with mental illness is perceived as contributing to negative public attitudes towards people with mental illness. Tragic and high profile killings by people with mental illness are often used to suggest that somehow so called “normal” people do not commit violent crime and if you do so, you must have a mental illness of some kind. It is a rare for a news story covering a homicide not to at least mention the mental health of the accused perpetrator.

The quotes throughout this post were from the first five news stories that came up when I searched Google for the word “Schizophrenic”. One is from a reader’s comment on the article. I decided not to use any more of these when even one article’s comments contained enough stigmatising language against people with mental illness to fill three textbooks and a toilet wall.

People with a diagnosis of schizophrenia in particular are often viewed as being violent and dangerous. Stigmatising language towards people with mental illness is often used to describe violent crimes where there is no apparent connection of the crime to the perpetrator’s mental health. If you don’t think so, you’re probably some kind of “psycho nutter”.

A paranoid schizophrenic stabbed his mother to death after convincing himself his parents were part of a satanic paedophile ring.

However, people with a severe mental illness are actually more likely to be victims of violence and crime than people in the general population. Where previous studies have investigated victims of homicide, people with a diagnosed mental illness were shown to have a 3-6 times higher risk, with higher risk still for people with diagnoses of alcohol and drug misuse.

Hit by a schizophrenic motorist who claimed voices in his head told him to drink-drive.

The study I’m summarising in this blog was conducted by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Their aim was to assess how often victims of homicide were current patients of mental health services.

This study aimed to assess how often victims of homicide are current mental health patients and their relationship to the perpetrators.

Methods

Data for the case series were collected over four stages:

Collection of a national sample of homicide victims for whom conviction of a homicide were recorded

Acquisition of the victims’ offending history

Identification of patient victims who had been under the care of the mental health services within a year of their death

Within the aforementioned group; collection of clinical data

The data for all suspected homicide offences in England and Wales between 1st January 2003 and 31st December 2005 were obtained from the Home Office Statistics Unit via the Homicide Index (comprehensive information about all offenses recorded as homicide).

This study only included confirmed victims of homicide. Information about the victims was sent to the main hospital and community National Health Service serving the health district in which the homicide occurred and in cases where the victim had contacted mental health services within the 12 months before their death, a questionnaire was sent to the clinician responsible for the patient’s mental health care. This questionnaire was completed along with members of the mental health team using the physician and team’s personal knowledge and the patient’s notes.

For the homicide perpetrators, the NCI database was used to determine whether they had been in contact with mental health services within the 12 months before their offense. Where contact had been made, a questionnaire was completed in a similar manner as for the victims.

Schizophrenic gunman laughed after shooting policewoman.

The study looked at all confirmed homicides during 2003-2005.

Results

The Victims

1,496 confirmed victims of homicide were identified, 69% of whom were male

The median age of victims was 35 years (range 0−94 years)

90 of the homicide victims (6%) had been in contact with mental health services in the 12 months prior to their death. This makes the homicide victim rate for mental health service users more than twice that of the rate in the general population (2.34 vs. 0.91 per 100,000 population)

More than a quarter of the victims had been subject to violence in the 12 months before their death, as documented in their case notes

Half of the people who were patients of mental health services and victims of homicide were killed by an acquaintance, a third by a family member, spouse or partner and a fifth by a stranger

The most common diagnoses for patients of mental health services who were also victims of homicide were schizophrenia, affective disorder and drug dependence

During the final contact with mental health services for the people who became victims of homicide, the risk for being a victim of violence was assessed in 67% of cases, although for most, the risk was judged as low or absent

Of the 90 victims of homicide who were also patients of mental health services, 32% were killed by another patient with a diagnosed mental illness

The Perpetrators

In the 3 year study period, 213 people with a reported mental illness were convicted of homicide, an average of 71 per year

The most common diagnosis for perpetrators of homicide who were also patients of mental health services was schizophrenia, 77% of whom had previously been convicted of a violent offense and 93% had co-morbid alcohol or drug misuse or dependence

This study shows that this deliberately inflammatory headline should actually be the other way round.

Conclusions

The authors concluded that specialist mental health providers in England and Wales can expect one of their patients to be a victim of homicide approximately every two years

It is likely that the rate of non-fatal violence towards people who are also patients of mental health services is much higher

Overall, the findings suggest that patients with a mental illness are two and a half times more likely to be victims of homicide than the general population

If you can put the blame on mental illness for this kind of behaviour then you need to be under lock and key as you’re a danger to society.

Limitations

The study only included victims of homicides that led to a conviction. The sample only contained people who were patients of mental health services and not people with a mental illness who were not under specialist mental health care. It is therefore likely that the study underestimates the true rate of mental illness in victims of homicide. However this should only serve to further highlight the vulnerability of this population.

The study was an observational design and so no causes or causal factors for the findings can be identified. This makes it difficult to make recommendations for the prevention of homicide against people with a mental illness from these findings alone.

The identification of patients with mental illness who are at risk from violence should be an important part of the clinical risk assessment.

Summary

The increased risk of people who have a mental illness and are patients of mental health services for being a victim of homicide should underline the need for services to protect such vulnerable adults.

The findings of this study also contain an anti-stigma message. That is to say that people with mental illness are often more likely to be victims of violence than perpetrators of violence. As such the identification of patients with mental illness who are at risk from violence should be an important part of the clinical risk assessment.

The media when reporting violent crime may want to refer to guidance from organisations like Mind and Time to Change, especially when that crime does have an actual connection to a person with a mental illness, Although as we have seen, the headline is more likely to be “Individual with history of mental health victim of crime” than “Individual with history of mental ill health commits crime.”

Dave Steele has degrees in Medicine and Applied Psychology. He has previously worked as an assistant for adults with learning disabilities, in psychology research (primarily schizophrenia and Alzheimers disease) and as a nursing assistant in an adolescent psychiatric unit.
He has a particular interest in mental health stigma having written blogs previously on the subject (among myriad others) and has provided psychiatry teaching material on the stigma of mental illness and the diagnosis and management of delirium. He is also interested in schizophrenia, old age psychiatry, liaison psychiatry and the organisation of mental health care.
He can be found on twitter, albeit talking about more varied (and most often nonsense) topics as @hullodave.

This title seems to be inaccurate. To quote from the abstract of the study in question:

“overall, the risk of patients committing homicide is greater than the risk of being a victim of homicide”.

This seems to directly contradict the claim you make when you write:

“That is to say that people with mental illness are often more likely to be victims of violence than perpetrators of violence.”

Given the extremely high rates of being a murderer (*as well as* being a victim) described in the study, it’s difficult to see why this would change anyone’s mind about the ‘stigma’ of schizophrenics being violent.